Consolidated CDA (C-CDA)
4.0.0 - STU4 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v4.0.0: CCDA 4.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Logical Model: Postprocedure Diagnosis

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PostprocedureDiagnosis Version: 4.0.0
Draft as of 2025-06-20 Computable Name: PostprocedureDiagnosis
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.51:2015-08-01

This template represents the diagnosis or diagnoses discovered or confirmed during the procedure. They may be the same as preprocedure diagnoses or indications.

Templates Used

Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:

Required EntryRelationships: ProblemObservation

Usages:

Changes since version 3.0.0:

  • The resource metadata has changed (description)

    • Formal Views of Template Content

    Description of Template, Differentials, Snapshots and how the different presentations work.

    This structure is derived from Act

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:postprocedure-dx 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Fixed Value: ACT
    ... @moodCode 1..1 cs Fixed Value: EVN
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 1..* EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: SUBJ
    ..... observation 1..1 ProblemObservation

    doco Documentation for this format

    Constraints

    IdGradePath(s)DetailsRequirements
    should-text-ref-valuewarningActSHOULD contain text/reference/@value
    : text.reference.value.exists()
    value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
    : value.exists() implies value.startsWith('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... templateId:postprocedure-dx 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
    Fixed Value: ACT
    ... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
    Fixed Value: EVN
    ... @negationInd 0..1 bl
    ... id 0..* II
    ... code 1..1 CD Binding: v3 Code System ActCode (example)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... qualifier 0..* CR
    .... translation 0..* CD
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
    .... @integrityCheck 0..1 bin
    .... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
    .... @language 0..1 cs
    .... @mediaType 0..1 cs Binding: MediaType (example)
    .... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
    .... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 0..1 CS Binding: ActStatus (required)
    ... effectiveTime 0..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..* Performer2
    ... author 0..* Author
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 1..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SUBJ
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 ProblemObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... reference 0..* Reference
    ... precondition 0..* Precondition
    ... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
    XML: precondition2 (urn:hl7-org:sdtc)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Act.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.templateId:postprocedure-dx.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.classCoderequiredFixed Value: ACT
    http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
    Act.moodCoderequiredFixed Value: EVN
    http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
    Act.codeexampleActCode
    http://terminology.hl7.org/ValueSet/v3-ActCode
    Act.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.text.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.text.compressionrequiredCDACompressionAlgorithm
    http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
    Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
    http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
    Act.text.mediaTypeexampleMediaType
    http://terminology.hl7.org/ValueSet/v3-MediaType
    Act.text.representationrequiredBinaryDataEncoding
    http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
    Act.statusCoderequiredActStatus
    http://terminology.hl7.org/ValueSet/v3-ActStatus
    Act.priorityCodeexampleActPriority
    http://terminology.hl7.org/ValueSet/v3-ActPriority
    Act.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Act.entryRelationship:problemObservation.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.entryRelationship:problemObservation.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ
    http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorAct.typeId, Act.entryRelationship:problemObservation.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()
    should-text-ref-valuewarningActSHOULD contain text/reference/@value
    : text.reference.value.exists()
    value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
    : value.exists() implies value.startsWith('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... templateId:postprocedure-dx 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
    Fixed Value: ACT
    ... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
    Fixed Value: EVN
    ... @negationInd 0..1 bl
    ... id 0..* II
    ... code 1..1 CD Binding: v3 Code System ActCode (example)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... qualifier 0..* CR
    .... translation 0..* CD
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
    .... @integrityCheck 0..1 bin
    .... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
    .... @language 0..1 cs
    .... @mediaType 0..1 cs Binding: MediaType (example)
    .... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
    .... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 0..1 CS Binding: ActStatus (required)
    ... effectiveTime 0..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..* Performer2
    ... author 0..* Author
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 1..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SUBJ
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 ProblemObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... reference 0..* Reference
    ... precondition 0..* Precondition
    ... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
    XML: precondition2 (urn:hl7-org:sdtc)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Act.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.templateId:postprocedure-dx.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.classCoderequiredFixed Value: ACT
    http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
    Act.moodCoderequiredFixed Value: EVN
    http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
    Act.codeexampleActCode
    http://terminology.hl7.org/ValueSet/v3-ActCode
    Act.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.text.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.text.compressionrequiredCDACompressionAlgorithm
    http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
    Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
    http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
    Act.text.mediaTypeexampleMediaType
    http://terminology.hl7.org/ValueSet/v3-MediaType
    Act.text.representationrequiredBinaryDataEncoding
    http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
    Act.statusCoderequiredActStatus
    http://terminology.hl7.org/ValueSet/v3-ActStatus
    Act.priorityCodeexampleActPriority
    http://terminology.hl7.org/ValueSet/v3-ActPriority
    Act.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Act.entryRelationship:problemObservation.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.entryRelationship:problemObservation.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ
    http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorAct.typeId, Act.entryRelationship:problemObservation.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()
    should-text-ref-valuewarningActSHOULD contain text/reference/@value
    : text.reference.value.exists()
    value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
    : value.exists() implies value.startsWith('#')

    This structure is derived from Act

    Summary

    Mandatory: 9 elements
    Fixed: 3 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 2 is sliced based on the values of Act.templateId
    • The element 1 is sliced based on the value of Act.entryRelationship

    Differential View

    This structure is derived from Act

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:postprocedure-dx 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Fixed Value: ACT
    ... @moodCode 1..1 cs Fixed Value: EVN
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 1..* EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: SUBJ
    ..... observation 1..1 ProblemObservation

    doco Documentation for this format

    Constraints

    IdGradePath(s)DetailsRequirements
    should-text-ref-valuewarningActSHOULD contain text/reference/@value
    : text.reference.value.exists()
    value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
    : value.exists() implies value.startsWith('#')

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... templateId:postprocedure-dx 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
    Fixed Value: ACT
    ... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
    Fixed Value: EVN
    ... @negationInd 0..1 bl
    ... id 0..* II
    ... code 1..1 CD Binding: v3 Code System ActCode (example)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... qualifier 0..* CR
    .... translation 0..* CD
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
    .... @integrityCheck 0..1 bin
    .... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
    .... @language 0..1 cs
    .... @mediaType 0..1 cs Binding: MediaType (example)
    .... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
    .... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 0..1 CS Binding: ActStatus (required)
    ... effectiveTime 0..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..* Performer2
    ... author 0..* Author
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 1..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SUBJ
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 ProblemObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... reference 0..* Reference
    ... precondition 0..* Precondition
    ... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
    XML: precondition2 (urn:hl7-org:sdtc)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Act.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.templateId:postprocedure-dx.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.classCoderequiredFixed Value: ACT
    http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
    Act.moodCoderequiredFixed Value: EVN
    http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
    Act.codeexampleActCode
    http://terminology.hl7.org/ValueSet/v3-ActCode
    Act.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.text.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.text.compressionrequiredCDACompressionAlgorithm
    http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
    Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
    http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
    Act.text.mediaTypeexampleMediaType
    http://terminology.hl7.org/ValueSet/v3-MediaType
    Act.text.representationrequiredBinaryDataEncoding
    http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
    Act.statusCoderequiredActStatus
    http://terminology.hl7.org/ValueSet/v3-ActStatus
    Act.priorityCodeexampleActPriority
    http://terminology.hl7.org/ValueSet/v3-ActPriority
    Act.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Act.entryRelationship:problemObservation.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.entryRelationship:problemObservation.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ
    http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorAct.typeId, Act.entryRelationship:problemObservation.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()
    should-text-ref-valuewarningActSHOULD contain text/reference/@value
    : text.reference.value.exists()
    value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
    : value.exists() implies value.startsWith('#')

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
    Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    .... templateId:postprocedure-dx 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.51
    ..... @extension 1..1 st Required Pattern: 2015-08-01
    ... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
    Fixed Value: ACT
    ... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
    Fixed Value: EVN
    ... @negationInd 0..1 bl
    ... id 0..* II
    ... code 1..1 CD Binding: v3 Code System ActCode (example)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Required Pattern: 59769-0
    .... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
    .... @codeSystemName 0..1 st
    .... @codeSystemVersion 0..1 st
    .... @displayName 0..1 st
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    .... originalText 0..1 ED
    .... qualifier 0..* CR
    .... translation 0..* CD
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
    .... @integrityCheck 0..1 bin
    .... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
    .... @language 0..1 cs
    .... @mediaType 0..1 cs Binding: MediaType (example)
    .... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
    .... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 0..1 CS Binding: ActStatus (required)
    ... effectiveTime 0..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..* Performer2
    ... author 0..* Author
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:observation
    .... entryRelationship:problemObservation 1..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SUBJ
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 ProblemObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... reference 0..* Reference
    ... precondition 0..* Precondition
    ... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
    XML: precondition2 (urn:hl7-org:sdtc)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Act.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.templateId:postprocedure-dx.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.classCoderequiredFixed Value: ACT
    http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
    Act.moodCoderequiredFixed Value: EVN
    http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
    Act.codeexampleActCode
    http://terminology.hl7.org/ValueSet/v3-ActCode
    Act.code.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.text.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.text.compressionrequiredCDACompressionAlgorithm
    http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
    Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
    http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
    Act.text.mediaTypeexampleMediaType
    http://terminology.hl7.org/ValueSet/v3-MediaType
    Act.text.representationrequiredBinaryDataEncoding
    http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
    Act.statusCoderequiredActStatus
    http://terminology.hl7.org/ValueSet/v3-ActStatus
    Act.priorityCodeexampleActPriority
    http://terminology.hl7.org/ValueSet/v3-ActPriority
    Act.languageCoderequiredAllLanguages
    http://hl7.org/fhir/ValueSet/all-languages
    From the FHIR Standard
    Act.entryRelationship:problemObservation.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.entryRelationship:problemObservation.typeId.nullFlavorrequiredCDANullFlavor
    http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
    Act.entryRelationship:problemObservation.typeCoderequiredFixed Value: SUBJ
    http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

    Constraints

    IdGradePath(s)DetailsRequirements
    II-1errorAct.typeId, Act.entryRelationship:problemObservation.typeIdAn II instance must have either a root or an nullFlavor.
    : root.exists() or nullFlavor.exists()
    should-text-ref-valuewarningActSHOULD contain text/reference/@value
    : text.reference.value.exists()
    value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
    : value.exists() implies value.startsWith('#')

    This structure is derived from Act

    Summary

    Mandatory: 9 elements
    Fixed: 3 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 2 is sliced based on the values of Act.templateId
    • The element 1 is sliced based on the value of Act.entryRelationship

     

    Other representations of profile: CSV, Excel